Breast Cancer, health and medical discussion help

Respond to the below post by discussing what kind of documentation (i.e. lab reports, radiology, etc.) the coder should look for in the medical record and any additional insight into the disease itself (medications, atypical signs and symptoms, etc.) or alternate names and common manifestations. Hint: code the disease using the ICD-10-CM codebook and look for any instructional notes and inclusion terms


Topic: Breast cancer.

This is one of the most common malignancy diseases affecting us today. Breast cancer forms in the cells of the breast and it is often hard to give an exact reason as to why this develops. The most common sign of breast cancer is a lump either in the underarm or in the breast. Knowing when something is abnormal with your own body is the most important protection and self breast exams are always recommended by physicians to help with early detection. Other symptoms that may be experienced are discomfort, bloody discharge from the nipple, changes in the shape and texture of the breast, and redness or swollen lymph nodes. When a lump is detected your physician may request you have an x-ray of the area along with a biopsy of the lump to determine if it is cancerous or not.

Treatments are always determined by the stage of the cancer and they include surgery, radiation therapy, medication therapy such as chemotherapy, and care from specialist to make sure the cancer is contained. Surgery could involve a mammaplasty, a lumpectomy, or a mastectomy. Radiation therapy is used to destroy cancer cell and shrink tumors while chemotherapy is used to kill cells that are multiplying quickly. In order to code this condition properly, the coder must know at what stage the cancer is at and what route of treatment the physician has decided to go in. Once a plan has been set in place the coding process can begin.

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